Under spring skies in Northern California’s Russian River Valley, Carol E. Miller recounts the day her struggle with survivor’s guilt began.

“I was 16 when the plane crashed,” she tells Yahoo Canada, close in age to two Parkland, Fla. shooting survivors who recently died in apparent suicides.

Miller was riding home from a family visit in Maine in a small airplane with her mother, father and younger sister, Nancy. Her father was piloting the plane when a carbon monoxide leak in the cabin knocked everyone out. Miller woke up trapped inside the wreckage.

She escaped the crash without serious injuries. Her sister died. Over the next month her mother would nearly die too. Both her parents were hospitalized for weeks with punctured lungs and other injuries.

The guilt set in too quickly for Miller to feel grateful for having survived. She blamed herself for suggesting the family fly that day.

“My psyche immediately started manufacturing ways for me to be guilty,” she says. “Every bit of news I received about the crash was another reason to feel guilty.”

Clinical psychologist and trauma specialist Dr. Vivien Lee says it is natural for a person who survives a deadly event to wonder why their life was spared while another person died. And sometimes, she says, survivors blame themselves because it is easier than accepting they were powerless to change the outcome.

“They have a hard time with it,” she says, “because to think that there’s nothing else you possibly could have done differently…that can lead to that sense of a lack of control.”

Miller laboured under guilt, depression and a lack of self-worth for years following the crash. When she was 19, a therapist she saw briefly tried to diagnose her with borderline schizophrenia. Miller didn’t know about post-traumatic stress disorder.

Many people experience symptoms of trauma in the weeks following an event such as a sexual assault, car crash or shooting. These symptoms can include excessive guilt, nightmares, difficulty sleeping, difficulty concentrating, flashbacks and mood swings.

While people usually process these feelings and begin recover after about a month, PTSD sufferers, who can’t process their trauma properly, experience symptoms for months or years.

“I didn’t know anything about PTSD back then, it wasn’t common knowledge,” Miller says. “It was in the dark ages in the early ‘80s.”

Students grieve during a candlelight vigil at Memory Mall on the UCF campus in Orlando, Fla., in commemoration of the one-year anniversary of the mass shooting at Marjory Stoneman Douglas High School. (Stephen M. Dowell/Orlando Sentinel/TNS via Getty Images)

She sees similarities between herself and the survivors of the Parkland shooting.

“I’ve been thinking a lot about it since hearing the news about the two Parkland teens in particular,” Miller says, referring to two teenagers who died by suicide a year after a shooting at Marjory Stoneman Douglas High School killed 17 of their teachers and classmates.

“The guilt becomes something that’s just too hard to carry when your peers or your family or your friends are not there and you are.”

Fortunately, Miller revisited therapy in her 30s and started to appreciate that the debilitating depression she had felt for decades was connected to the crash.

“When I finally agreed to consider that trauma was a factor, when I let that in, then together with my therapist we were able to start creating an opening and generate a willingness on my part…to turn over some rocks and look at what was underneath,” Miller says.

As well as traditional psychotherapy and EMDR therapy, Lee says there are several treatments for PTSD endorsed by the American Psychological Association and the National Centre for PTSD, including prolonged exposure therapy and cognitive processing therapy.

There are no evidence-based treatments specifically for survivor’s guilt, which can be present with or without PTSD, but Lee says sufferers can process it through psychotherapy and cognitive behavioural therapy.

“It’s trying to come up with more balanced thinking, that’s one way to go about it,” she says. “Other people just need to talk it out of their system. If they do that, sometimes they just start healing themselves.”

The role others play

Lee and Miller warn that PTSD can be alienating for people who suffer from it.

“When we’re feeling like our minds and bodies are out of control…we feel very alone,” Lee says. “We feel crazy, like no one else can understand.”

For Miller, isolation imposed by years of trauma reinforced her belief that she wasn’t worthy of other people’s company, empathy or love. Today, she knows better.

“If people in our families, our communities, our schools are suffering from trauma, we’re part of that unit,” Miller says. “And so it behooves us to educate ourselves and to try and understand what is happening.”

Lee encourages people to think of PTSD as an issue of physiology in order to better understand it.

“Every time I talk to someone new and go over trauma, I talk about the physiology,” Lee says. “Our fight, flight, freeze response is so powerful…We can’t just turn it off.”

People hug as they visit a memorial set up near the Marjory Stoneman Douglas High School in honor of those killed. (Photo by Joe Raedle/Getty Images)

Our brain’s threat-detection centre tells us to fight, flee or freeze in the face of immediate danger. In a PTSD sufferer, stress and reminders of a traumatic event can trigger that response even in the absence of real danger.

“This is a very powerful visceral response we all have, and when there’s a traumatic event, it’s activated,” Lee says. “So it’s recognizing that this isn’t under our control, we can’t just snap out of it.”

Instead, Lee says people who suspect a friend or loved one might suffer from PTSD should be present and patient and, if they think that person needs help, gently discuss their concerns.

A person suffering from PTSD might be preoccupied with a traumatic event they experienced months or years ago and may become emotionally distressed when talking about it. Another might avoid talking about it and become withdrawn and disinterested in activities they used to enjoy.

“One way to open the door that people have found helpful is to talk about something you’ve noticed that changed in their day-to-day,” she says. “They might not be able to go through the door at that time, but you’ve opened it to them.”

Ultimately, someone close to Miller urged her to give therapy another try when, decades after the crash, depression was still ruling her life. Because of the work she has done since then, she can now share her story with others.

“I’ve had my share of trauma,” she says. “But the fact that I’m sitting here saying that and giggling about it probably tells you I’m making considerable strides.”